Emergency Medicine

286 Orthopaedic Emergencies

INJURIES TO THE ELBOW AND FOREARM

5 Perform a post-reduction X-ray and refer all cases to the orthopaedic team

for neurovascular observation.

6 Also refer complicated cases to the orthopaedic team, which include commi-

nuted fracture of the radial head, humeral epicondyles or coronoid process,

or t hose t hat were not able to be reduced.

Pulled elbow

DIAGNOSIS

1 This is common in children aged 2–6 years and usually follows axial traction

applied to an extended arm, for example when pulling a child’s hand to

prevent a fall or to put on a sweater.

(i) However, about half the cases report no history of trauma.

2 The radial head is subluxed out of the annular ligament, causing local pain

and loss of use of the arm, particularly supination.

3 Examination reveals an anxious child protecting the affected arm, which is

held by the side, with the elbow semi f lexed and pronated. There is no

neurovascular compromise and motor activity is normal.

4 X-rays are usually not necessary, but should be performed to exclude a

fracture if there is extensive swelling over the elbow, or if reduction is not

successful after two or three attempts.

MANAGEMENT

1 Fix the elbow and apply pressure to the region of the radial head with one

hand. Applying axial compression at the wrist, supinate the forearm and

gently f lex the elbow with the other hand.

(i) The radial head is felt to click back in the majority of cases.

(ii) If reduction fails, ensure the diagnosis is correct, then place in a

broad arm sling and arrange fracture clinic follow up. Most cases

resolve spontaneously within 48 h.

2 The child is often still reluctant to use the arm for the first 15–30 min follow-

ing reduction, and so observe in the ED until adequate return of function has

been demonstrated.

3 No immobilization is required unless reduction fails. Discharge the child

with the parents following education to prevent a recurrence.

Fractures of the olecranon

DIAGNOSIS

1 These fractures follow a fall on to the point of the elbow or forced triceps

contraction, which may then distract the olecranon, leaving a palpable

subcutaneous gap.